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OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Initial Assessment and Initial Assessment Plan

Policy #:

VR-09-01

Code/Rule Reference:

O.A.C. 4123-18-02; O.A.C. 4123-18-04; O.A.C. 4123-18-05

Effective Date:

10/10/16

Approved:

Deborah Kroninger, Chief of Medical Operations (Signature on file)

Origin:

Vocational Rehabilitation Policy

Supersedes:

All vocational rehabilitation policies, procedures, directives and memos regarding initial assessments and initial assessment plans that predate the effective date of this policy and procedure.

History:

New

Review date:

10/10/19

 

 

I. Policy Purpose

 

The purpose of this policy is to ensure that a thorough initial assessment is completed, including an initial assessment report and an assessment plan, when needed.

 

II. Applicability

 

This policy applies to the:

·         BWC disability management coordinators (DMCs);

·         Managed care organization (MCO) staff involved in the coordination and management of the vocational rehabilitation program; and

·         Vocational rehabilitation case managers (VRCMs) assigned by the MCO.

 

III. Definitions

 

See “Vocational Rehabilitation Definitions” in Chapter 4 of the MCO Policy Reference Guide.

 

IV. Policy

 

It is the policy of BWC that a thorough initial assessment will be conducted to develop information and make recommendations to best serve the vocational needs of the injured worker (IW). 

 

V. Procedure

 

A.    Contacts

1.    To begin the initial assessment phase, the VRCM shall contact the IW, the employer of record (EOR), the physician of record (POR), the MCO and the DMC as provided in section V.A.2-7, below. The VRCM may contact other people, as needed, that may provide information related to the IW’s vocational needs.

a.    The VRCM shall use all contacts as a means of establishing a good working relationship that will aid in the sharing of information and generally contribute to the IW’s successful vocational outcome.

b.    The VRCM shall ensure that a proper authorization to release information is signed by the IW before contacting the POR or any other provider.

c.    The VRCM shall document the time and date of each contact or attempted contact, the name of the person contacted and the information received.

d.    If, for any reason, a required contact cannot be made (e.g., the EOR is out of business), the VRCM shall clearly document the circumstances.

2.    IW Contact – The VRCM shall contact the IW within five (5) days of case assignment to schedule a face-to-face initial interview. The VRCM shall gather the following information and/or documents, if not already in the vocational documents, during this interview (not an exhaustive list):

a.    The IW’s hard copy signature on the Rehabilitation Agreement (RH-1) acknowledging the IW’s interest in vocational rehabilitation services;

b.    Any medication usage, prescribed or over-the-counter, frequency, dose and prescribing source;

c.    Demographics (e.g., age, marital status, number of dependents, transportation issues);

d.    Education;

e.    Employment history (e.g., previous employment, job descriptions, reasons for leaving any prior employment, union affiliations, military service);

f.     Legal considerations (e.g., arrests, convictions, pending legal matters, non-citizen work status);

g.    Medical concerns (e.g., abilities and limitations, unrelated medical or mental conditions, medical insurance);

h.    Financial disincentives (e.g., other financial benefits, other household income);

i.      BWC Information (e.g., any previous claims, pending hearings); and

j.      Vocational rehabilitation participation information (e.g., any previous vocational rehabilitation including participation through other agencies).

3.    Employer Contact

a.    The VRCM shall, whenever reasonably possible, visit the EOR or current employer’s worksite and meet with the employer representative responsible for decisions regarding the IW’s work status.

b.    If a visit to the employer is not reasonably possible, the VRCM shall make telephone contact.

c.    The VRCM shall:

i.      View and/or obtain a detailed description of the work environment and job tasks performed by the IW in order to determine if job modifications or alternative jobs may be available to the IW;

ii.     Discuss opportunities for transitional work, RTW and/or other services with the employer representative; and

iii.    Obtain information about the IW’s work strengths.

4.    POR Contact – The POR shall be contacted, preferably in person.

a.    The VRCM shall obtain from the POR any documentation of:

i.      The IW’s current physical restrictions related to the allowed conditions;

ii.     Current medications; and

iii.    Any needed prescription for plan services.

b.    The VRCM shall discuss with the POR:

i.      The IW’s medication usage and specifically how this may impact the IW’s ability to perform specific work tasks (e.g., operate machinery, drive);

ii.     The IW’s restrictions as they relate to the IW’s targeted job goal, using the job description or job analysis;

iii.    The RTW options available through the employer, including transitional work or other early RTW services; and

iv.   The IW’s ability to participate in vocational rehabilitation services.

5.    MCO Contact – The VRCM shall contact the MCO to:

a.    Obtain any recent information received in the claim, especially any recent treatment requests and their status;

b.    Obtain feedback regarding vocational rehabilitation services for the IW;

c.    Obtain assistance with gathering information from medical providers or the EOR, if needed; and

d.    Staff current strategy and recommendations.

6.    DMC Contact – The VRCM shall contact the DMC to:

a.    Obtain any information from the source claim or other claims, if necessary;

b.    Obtain feedback regarding vocational rehabilitation services for the IW;

c.    Obtain any wage or compensation information; and

d.    Staff current strategy and recommendations.

7.    Attorney of Record (AOR) Contact – The VRCM shall contact the AOR, if applicable, to:

a.    Update the AOR on the status of the initial assessment and recommendations;

b.    Provide contact information;

c.    Obtain AOR input; and

d.    Enlist AOR assistance with the IW, if necessary.

 

B.    Complexity Factors: Throughout the initial assessment phase, the VRCM shall begin identifying the barriers and issues that create complexity in the case and noting these issues on the Complexity Factors Reporting Form.

 

C.   The Initial Assessment Report

1.    Job Retention: The VRCM is not required to complete an initial assessment report for job retention services. The VRCM will proceed directly to a job retention plan (See the Job Retention Plan Development and Implementation policy and procedure for further information).

2.    Except for job retention services, the VRCM shall, within twenty-one (21) days of an assignment, complete and submit to the MCO and the DMC an initial assessment report using the Vocational Rehabilitation Initial Assessment Report (RH-42). The report shall:

a.    Summarize and document the current vocational factors identified by the VRCM;

b.    Identify vocational barriers and strengths;

c.    Identify additional vocational questions, if any; and

d.    Include a recommendation for:

i.      Case closure; or

ii.     Development of an assessment plan to answer any identified questions and/or obtain additional information; or

iii.    Development of a comprehensive vocational plan.

3.    The MCO shall ensure that the initial assessment report is provided on the current form and submitted within 21 days of assignment.

4.    If the report cannot be completed within the 21-day timeframe, the VRCM shall submit to the MCO a written justification for the delay, the current status and the projected submission date for the report.

5.    The MCO shall confirm that:

a.    The initial assessment report is reasonably based and that any subjective inferences are substantiated with an objective behavioral description;

b.    Appropriate authorizations for the release of information were signed by the IW before the VRCM contacted the POR and any other providers;

c.    The VRCM submits the initial assessment report before any plan services are authorized or delivered; and

d.    The Rehabilitation Agreement (RH-1) and the authorization for release of information are submitted no later than the submission of the initial assessment report.

 

D.   Assessment Plan

1.    The VRCM, DMC and MCO shall staff any recommendation for an assessment plan.

2.    Within 28 days of assignment and upon agreement of the DMC and MCO, the VRCM shall develop and submit the assessment plan, using the BWC form Vocational Rehabilitation Assessment Plan (RH-43).

3.    The VRCM shall ensure all sections of the RH-43 are complete.

4.    The VRCM shall:

a.    Describe in detail each service needed;

b.    The rationale for that service; and

c.    The specific questions to be answered by the service, as applicable.

5.    The VRCM may include in the assessment plan, as appropriate, the following reimbursable services and activities (not an exhaustive list):

a.    Vocational evaluation;

b.    Evaluation of functional and physical capacity;

c.    Multi-disciplinary evaluation;

d.    Evaluation by a physical medicine and rehabilitation physician;

e.    Psychological evaluation;

f.     Work conditioning evaluation;

g.    Vocational screening;

h.    Situational assessment;

i.      Career counseling;

j.      Informational interviews;

k.    Pre-test for GED;

l.      Job analysis;

m.   Ergonomic study;

n.    Transferable skills analysis (this may be conducted by the VRCM during the initial assessment);

o.    Labor market survey;

p.    Vocational rehabilitation case management for assessment and plan development (W3000-W3040);

q.    Travel; and

r.     Other services as authorized by the MCO.

6.    The following are not appropriate services for an assessment plan:

a.    Employment services;

b.    Work adjustment;

c.    Actual training;

d.    Therapy;

e.    Conditioning;

f.     Job modifications; and

g.    The provision of tools and equipment.

7.    The DMC shall authorize any of the following special assessment plan types prior to the beginning of services (See the Special Vocational Plan Types policy and procedure for further information):

a.    Plans developed by a vocational rehabilitation case management intern - The DMC shall be notified of the assignment of an intern at the time of assignment or transfer.

b.    Extension of reimbursable service guidelines - The DMC shall enter a claim note indicating approval or denial of a service that exceeds the service code limit or exceeds the fee schedule.

c.    Plans requiring interpreter services - The DMC shall be responsible for arranging and authorizing interpreter services at critical junctures in the rehabilitation case, as necessary. See the Interpreter Services policy and procedure for additional information.

d.    Plans with services paid “by report” (plans that include service codes that  have no established fees for the identified service)  See the Provider Billing and Reimbursement Manual for information on “by report” services.

8.    The VRCM shall design the assessment plan to be completed within 28 days.

9.    The MCO and DMC shall review the assessment plan and, if in agreement, the VRCM shall proceed with services.

10.  If unusual circumstances exist and the VRCM determines that additional assessments are needed:

a.    The VRCM shall submit an amended assessment plan with justification for the additional services to the MCO.

b.    The MCO shall consult with the DMC and approve or disapprove the amended assessment plan.

11.  Signature Requirements

a.    On an RH-43 (both the original assessment plan and an amended assessment plan), the MCO shall require a hard copy signature from the:

i.      VRCM;

ii.     MCO; and

iii.    The IW within thirty (30) days.

b.    When the VRCM initially receives verbal approval from the IW, the VRCM shall:

i.      Initial and date the appropriate “Plan of service approval” section, which serves to attest the verbal approval was received from the IW awaiting the approval of the MCO; and

ii.     Within 30 days of the assessment plan start date, obtain and submit the IW’s hard copy signature to the MCO and DMC.

c.    The MCO shall not accept an email- generated (i.e., typed) signature as a hard copy signature. The MCO shall accept a scanned document sent via fax or email which reflects a hard copy signature.

 

E.    Living Maintenance (LM)

1.    The DMC shall evaluate and facilitate, when appropriate, payment of LM to the IW during the IW’s participation in an assessment plan.

2.    LM shall start on the first day of the IW’s participation in the assessment plan and continue throughout the period the IW is participating in the assessment plan.

3.    The IW may continue to receive LM for up to 14 days following completion of the assessment plan if a comprehensive vocational rehabilitation plan is being developed.

4.    For further information on LM, refer to the Living Maintenance Compensation policy and procedure.

F.    Employability Recommendation

1.    Within seven days of the IW’s completion of active services in an assessment plan, the VRCM shall complete a written employability recommendation to the MCO. (This step occurs during the time allotted on the assessment plan for comprehensive plan development).

2.    The employability recommendation shall summarize and integrate results from all the assessments completed and outline vocational rehabilitation service options including:

a.    The type of assessment;

b.    The provider; and

c.    Recommendations as to whether the IW is a viable candidate at this time for participation in a comprehensive vocational rehabilitation plan for purposes of RTW.

i.      If the VRCM determines that the IW is not a viable candidate and therefore not feasible for vocational rehabilitation services, the MCO shall follow the procedures for case closure (See the Vocational Rehabilitation Case Closure policy and procedure).

ii.     If the VRCM determines the IW is a viable candidate, the VRCM shall outline the service options and staff the recommendations, preferably via telephone, with the MCO and the DMC.

 

G.   Reopened Cases

1.    Cases closed during or after the assessment plan may only be reopened with justification of significant changes in the IW’s circumstances.

2.    If a comprehensive vocational rehabilitation plan is reopened within two months of closure due to a rescinded closure or claim transfer, another initial assessment is not necessary.

 


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